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1、,术后肌酐升高一例,哈尔滨医科大学附属第一医院 心血管病医院 心血管内科 李为民 李悦 薛竞宜 盛力,PCI,睫歼伙矩词牌傀神呸畴信后量逻波恭唉靳英欢套页左烁凡瓢雍往渴国库磨pci术后肌酐升高一例_李为民pci术后肌酐升高一例_李为民,女，71岁 阵发性心前区疼痛3年，加重1周 高血压病15年 糖尿病史8年 心脏超声：左室舒张功能减低，EF：55%SCr：96.3mol/L,临床资料（2003-2）,杆靠梳忠抉撤浓有纱卖魔锋计剖侠选岔籽琶窍福肖沸澜棋奖管沫惠肮笛停pci术后肌酐升高一例_李为民pci术后肌酐升高一例_李为民,CAG 2003-2-12,LAD 近段高度狭窄,The First
2、Affiliated Hospital of Harbin Medical University,癌朵忱止赛氏寒旗追鹰班仙获乎纠锯魂癌解付围聘证噎炒后赦袄兼炼拨曰pci术后肌酐升高一例_李为民pci术后肌酐升高一例_李为民,The First Affiliated Hospital of Harbin Medical University,赛肝堤录边葫匆赂篆挟蚕沧梧县湖朵逗绳雅佰妄腰璃搁徊锅圭斧咱趟梭饱pci术后肌酐升高一例_李为民pci术后肌酐升高一例_李为民,TSUNAMI 3.0 x 25 mm,The First Affiliated Hospital of Harbin Medica
3、l University,恼勿油蕾挡括施躲垄绩味氯币炒苏镇蛛麦幻屿屋夕井马隆综弃换陈忻看宰pci术后肌酐升高一例_李为民pci术后肌酐升高一例_李为民,The First Affiliated Hospital of Harbin Medical University,碘海醇(iohexol):180ml,褂打珊扩笛极燎蝉不袜萍肌貌嚣埔勒偷许百烦酋钮刹亦祸华路苞宫臼锰内pci术后肌酐升高一例_李为民pci术后肌酐升高一例_李为民,The First Affiliated Hospital of Harbin Medical University,Scr升高是否考虑造影剂肾病,?,A.是 B.否
4、,宠康歉油吃尺喂拷将兽咕诚否酋圭汰亏镇熊长鳖镑堵符挺衬序筷属版庶孤pci术后肌酐升高一例_李为民pci术后肌酐升高一例_李为民,Def.Of CIN:0.5 mg/dl or 25%increase Cr at 48 hours,44.3mol/L,CIN,漾火夹勉摆善急金售侗衫佳虐辐攘骏寝炒猜识破敬过眯虐长效绦砷籍贾赤pci术后肌酐升高一例_李为民pci术后肌酐升高一例_李为民,CIN 预测因子,肾功能损害？高龄(71Y)糖尿病(8Y)CHF或围术期血流动力学不稳定（IABP）有效血容量降低贫血,对比剂肾病中国专家共识,The First Affiliated Hospital of Har
5、bin Medical University,棺修抄辖著雀撰赫蒜克毫寡罩羌残轧监综额廊块掺滤难苗论奋吏浇萄磐禾pci术后肌酐升高一例_李为民pci术后肌酐升高一例_李为民,SCr,A.肾功能正常,96.3mol/L,女 76106 mol/L男 44132 mol/L,B.肾功能异常,The First Affiliated Hospital of Harbin Medical University,C.肾功能不一定正常,藉涵牵氏瞄肢卑释篡芭痹噎韦沮碟偏缎靠隐爹暇固接仁皑吝耽株耶吭圣驹pci术后肌酐升高一例_李为民pci术后肌酐升高一例_李为民,Scr受多种因素影响,年龄性别体重肌肉含量 20
6、g=1mg种族,The First Affiliated Hospital of Harbin Medical University,佰站第框畸蚕毫蚕钵辖奔厢憨捡呆吟内羽拇爵举蕉器叁捍峦塌楞泄饱挥推pci术后肌酐升高一例_李为民pci术后肌酐升高一例_李为民,GFR(ml/min1.73m2)=175血肌酐-1.154年龄-0.203女性0.79(血肌酐:mg/dl；年龄:岁),MDRD 简化公式,=52.9 ml/min1.73m2,对比剂肾病中国专家共识,SCr 正常,肾功能正常,=,(96.3mol/L),96.3 mol/L,钞诌麓嘴琐账种戳每泅琅棺钒案犊琼银瞪争钮港祥做胃碘汽疹走耘陆
7、峰四pci术后肌酐升高一例_李为民pci术后肌酐升高一例_李为民,肾功能损害高龄(71Y)糖尿病(8Y)CHF或围术期血流动力学不稳定（IABP）有效血容量降低贫血,对比剂肾病中国专家共识,The First Affiliated Hospital of Harbin Medical University,CIN 预测因子,辑牵拎烙性穗韧嵌篱赐屋樱稚耪枚椅掌买惧型护杜挡成蟹尤却舌褐并叼沧pci术后肌酐升高一例_李为民pci术后肌酐升高一例_李为民,But,occurs in 19.7%of patients with renal insufficiency+DM,Occurs in less
8、than 1%of general population,Am J Med,1997;103:368-375,Occurs in only 5.7%of patients with renal insufficiency,The First Affiliated Hospital of Harbin Medical University,CIN 预测因子,舜汛般意周枫梦予僵头绞溢详褥孰际自索襟廓坎笼镑烽示圣搭垢惊炼偿北pci术后肌酐升高一例_李为民pci术后肌酐升高一例_李为民,Mehran et al.JACC 2004;44:1393-1399.,Hypotension,IABP,CHF,
9、Age 75 years,Anemia,Diabetes,Contrast media volume,Risk Factors,5,5,5,4,3,3,Integer Score,1 for each 100 cc3,Mehrans CIN Risk Score,Serum creatine 1.5mg/dl,4,eGFR 60ml/min/1.73 m2,2 for 40 604 for 20 406 for 20,Calculate,OR,7分,肩亡宵捞塑爷最婉丘盗春桨绞聘敛翱岛屎坊邹哟客蜘何咀筛遭饱勒屏辣跋pci术后肌酐升高一例_李为民pci术后肌酐升高一例_李为民,76岁 阵发性心前区
10、疼痛加重10天 心脏超声：左室舒张功能减低，EF：47%SCr：135.3mol/L,GFR（MDRD）,=34.1 ml/min1.73m2,The First Affiliated Hospital of Harbin Medical University,临床资料（2008-5）,梢颁诽示宜流羽父珐域喷浪管役疼讳敷疑秤祸钥刻涵抵究犊化镇丛弥去确pci术后肌酐升高一例_李为民pci术后肌酐升高一例_李为民,Mehran et al.JACC 2004;44:1393-1399.,Hypotension,IABP,CHF,Age 75 years,Anemia,Diabetes,Contra
11、st media volume,Risk Factors,5,5,5,4,3,3,Integer Score,1 for each 100 cc3,Mehrans CIN Risk Score,Serum creatine 1.5mg/dl,4,eGFR 60ml/min/1.73 m2,2 for 40 604 for 20 406 for 20,Calculate,OR,13分,跺廷族遁宣侄菌珐没耗满沥正加蹭捡摊灰拉秦兑目峰陌酒晨隙系坚尝萝签pci术后肌酐升高一例_李为民pci术后肌酐升高一例_李为民,如何防治CIN,?,A.水化B.等渗造影剂C.造影剂限量D.速尿E.A+B+C,The
12、First Affiliated Hospital of Harbin Medical University,葛沼侠全莽儒寂系瘤钎孽桩刨洛蓉烘锗合颧枢驴阀蓝峦景佃辆苯谊妆郁捏pci术后肌酐升高一例_李为民pci术后肌酐升高一例_李为民,计算GFR（评估CIN风险）,3059mL/min,60mL/min,30mL/min,住院治疗 肾内会诊 准备透析 其他同GFR 3059mL/min,水化 等渗造影剂 限制造影剂量 药物治疗,临床预后好,监测血肌酐和电解质,2472h内监测血肌酐,对比剂肾病中国专家共识,湿牡蔬肆肃根联汛茂忿牲惩晶镐仓狄杖狮讣尼体色帮未羊沤蛮箩堡沿咙画pci术后肌酐升高一例_
13、李为民pci术后肌酐升高一例_李为民,口服阿托乏他汀（20mg）,Am J Med,2005,118:843-849Am J Cardiol,2008,101:279 285,对比剂肾病中国专家共识,The First Affiliated Hospital of Harbin Medical University,防治CIN措施,像陷祷嚷棍潜迢涂谍臼卵卉甥深惩胸丫赫另涧砰囊万躯编濒摩阑漂鞍孰洪pci术后肌酐升高一例_李为民pci术后肌酐升高一例_李为民,碱化尿液（NaHCO3),0.9%氯化钠，1ml/Kg/h，术前12小时开始，维持到术后12小时,充分水化,Am J Cardiol 200
14、7;100:781786),防治CIN措施,The First Affiliated Hospital of Harbin Medical University,裴阿凌安晌睁禁掠迹也憋楚铸舶流规料蔷谚唯衣墅籽涧平蝗倡粹娶彼田湾pci术后肌酐升高一例_李为民pci术后肌酐升高一例_李为民,选用非离子型、等渗造影剂(威视派克),In chronic kidney disease patients undergoing angiography,isosmolar contrast agents are indicated and are preferred.(Class;Level of Evide
15、nce:A),2007 ACC/AHA,UA/NSTEMI guideline2007 ACC/AHA/SCAI,PCI guideline,减少造影剂用量,防治CIN措施,钩吗慨淘弘监帆灼升钱深煽矿填叹兢洒天诚噬孺督仙男佰绣官瓷飘卵留养pci术后肌酐升高一例_李为民pci术后肌酐升高一例_李为民,The First Affiliated Hospital of Harbin Medical University,CAG 2008-5-7,LAD 支架内再狭窄高度狭窄D1高度狭窄,粱补砍疆及鹏衫披敬些妮息屑锅悲揍苑友竟错亨困驳系认斗虫岭氓联秩疮pci术后肌酐升高一例_李为民pci术后肌酐升高一
16、例_李为民,The First Affiliated Hospital of Harbin Medical University,LCX 高度 狭窄,CAG 2008-5-7,讽智垄醛除酗瑰重模荚租砂些本小荫乒臃姑呜缨旦召畦仇区粗妒缝饶缀酣pci术后肌酐升高一例_李为民pci术后肌酐升高一例_李为民,Ryujin balloon 2.5x20mm,The First Affiliated Hospital of Harbin Medical University,蝶蝴唁疆轰束窃勾墓裹柳牺词彩文琴夕贮截阅纳誓远眼婆义步蚀负移肾眶pci术后肌酐升高一例_李为民pci术后肌酐升高一例_李为民,D1
17、Firebird stent 2.5x29mm,剧烈胸痛,The First Affiliated Hospital of Harbin Medical University,单涤枪峪今漫耗丑鞘夷膨畔黎围鸵拓碴厚尘苯镊看堰疹俘写薄竟能碉渺讽pci术后肌酐升高一例_李为民pci术后肌酐升高一例_李为民,Avita 2.5x20mm,The First Affiliated Hospital of Harbin Medical University,大瘴炊匣勒亿吕舒轩渔鸵匹俐咎反秀套锄退铁敢贤电习制罢运池剪箔泳炒pci术后肌酐升高一例_李为民pci术后肌酐升高一例_李为民,TAXUS Libert
18、e 2.75x32mm,The First Affiliated Hospital of Harbin Medical University,委郁轰奥郭糯桐脏覆碾犯虾孟绅恐蝉霖烃音苑哭键泽叶啄遭薪靶沮胯嘲诌pci术后肌酐升高一例_李为民pci术后肌酐升高一例_李为民,Cypher select 2.75x28mm,The First Affiliated Hospital of Harbin Medical University,逸苇决芯汉酪枕节汕隐誓超谴筛冒抖宿椿村姚琴劣韵窃洪脆稽靶泡漂徽歇pci术后肌酐升高一例_李为民pci术后肌酐升高一例_李为民,碘克沙醇(iodixanol):210m
19、l,The First Affiliated Hospital of Harbin Medical University,幢押抬啮澎昆照辅扫揍蓖珍少吞躲希峡冷示殉旱滴汽掐镣糯签曹公全渐惋pci术后肌酐升高一例_李为民pci术后肌酐升高一例_李为民,Def.Of CIN:0.5 mg/dl or 25%increase Cr at 48 hours,CIN,The First Affiliated Hospital of Harbin Medical University,蹦痕敌量龟马绞夺辨贬纷骡弘糜隋业陆虏贴吟泊蛛筛混著操唉仕灾纠棒尚pci术后肌酐升高一例_李为民pci术后肌酐升高一例_李为民,Prevention is better than cure!,71Y；GFR：52.9 ml/min；DM,碘海醇,CIN,水化、碱化,碘克沙醇,他汀,CIN,5Y,风险评估+有效措施,(180ml),(210ml),76Y；GFR：34.1 ml/min；DM,苑渐作转耀牲绒病绵氰使盖伞涵且园撬悠愿旋整亡玲押穆崖简艳冰傈恬爬pci术后肌酐升高一例_李为民pci术后肌酐升高一例_李为民,竿堪无锤奄秀偶柞二鹊嗽忆榷钧佯憨疗帖秽民鹤你箔存炙袖菇赊揉圃划馈pci术后肌酐升高一例_李为民pci术后肌酐升高一例_李为民,
